How does the operation of PHARMAC's 'Community Exceptional ...

for example value for money, equity or affordability. These values are described
in the New Zealand Medicine Strategy (Minister of Health, 2007) as values
which must be considered in decision making. This process eventually
develops a lexicographical ordering of priorities based on each panel member’s
preferred selections.
Such frameworks require at some point the ranking of priorities of moral and
ethical judgments. The research has demonstrated that approaches to carrying
out such judgments are morally disputed. The data from the OIA requests to
PHARMAC showed that doctors on the panels are there to rule on clinical
matters. PHARMAC does not explain how these panellists are qualified (or
entitled), more than any other citizen, to impress their own moral judgments on
the outcomes of PHARMAC’s decisions. However, moral sensitivity and ethical
reflection should be an integral part of the allocative decision making process
(UNESCO, 2005). This is affected by the wider community, not just the expert
medical practitioners chosen by PHARMAC to populate the various panels.
Consequently, Gillon asserts that in the absence of a stated philosophical basis
for PHARMAC’s decision making, Hansen’s system is undermined.
Hadorn (2006) submitted to the Review of High-Cost Medicines that PHARMAC
lacked the ability to introduce discussions about fairness into the decision
making processes, particularly decisions about providing (or not providing)
subsidies for high-cost medicines for individuals. He appealed to the distributive
justice principles of Rawls and suggested that PHARMAC introduce a
“Rawlsian Wrinkle” into the decision making process (Hadorn 2006). He
described this wrinkle as aligned to Rawls’ difference principle, where the
needs of the least well off are considered before the needs of the most well off.
This suggestion was not meant to undermine the clinical effectiveness or value
for money assessments already carried out by PHARMAC. The wrinkle was
suggested to add an assessment of fairness and equity into the wider utilitarian
processes.
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